Nursing Case Study: Postoperative Care and Management of Ted Williams

This case study focuses on the postoperative care of Edward (Ted) Williams, an 82-year-old male who underwent a bowel resection and colostomy. The assignment addresses the biopsychosocial, spiritual, and cultural impacts of the surgery, patient problems based on collected information and pathophysiology, and nursing interventions to manage ineffective breathing patterns and pain. It explores the patient's medical history, vital signs, and medications. The study also includes a discussion of two classes of drugs used to manage Ted's postoperative condition, including analgesics and ACE inhibitors, detailing their pharmacodynamics and rationale for use. The case study highlights the importance of comprehensive patient assessment, evidence-based interventions, and holistic care in the postoperative setting, with emphasis on addressing complications such as pulmonary edema and sepsis.

Running head: POST-OPERATIVE CARE 1
Postoperative Care
Students Name
Institutional Affiliation

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Question one
Edward Williams, an 82-year-old male, has a temporary colostomy after a bowel
resection was done. He had previously had a biopsy and colonoscopy, which revealed a
malignant mass. He has a distended abdomen with abdominal pain that worsens on palpation. He
currently has a colonoscopy and urinary catheter in situ. Surgical outcomes or complications
appear to have a substantial effect on patient's biopsychosocial, spiritual, and cultural issues
(Klaseem, Ouden, & Schuurmans, 2015). The client may experience different challenges due to
complications that result in long term disability that might affect activities of daily living such as
communication, elimination, breathing, mobilization, and dressing.
Loss of control over the elimination of feces may result in embarrassment and social
isolation. The client might experience psychological symptoms such as depression and anxiety,
which might result in suicidal ideation (Jayarajah & Semarasekera, 2016). Body image is a vital
psychosocial issue since it changes functioning and appearance. The client may have problems in
dressing, working, and playing. The appearance changes may induce feelings of lack of
masculinity, disfigurement, inferiority, feeling angry at one, and also feeling alienated from the
body (Kyung, Young, & Kwang, 2017). Loss of bodily functions changes an individual's self-
worth. In addition to interfering with the perception of body image, it might result in thoughts of
no longer being a human and fear of not able to live a healthy life. Cultural background plays a
significant role in the patient's beliefs, whether personal or religious (Liao & Qin, 2015). Ostomy
surgery changes an individual perception of God. The individual might avoid going to church or
mosque due to loss of control over elimination and disturbed body image. The patient might get
angry at God, asking God why they had to go through the problem.
Question two

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Ted had previously had a biopsy and colonoscopy that revealed a malignant mass. He has
a history of heart failure, gout, type 2 diabetes, and obesity. His vital signs at 10am were as
follows: T 38.1; HR 98 reg; BP 135/85; RR 26; SpO2 94% on 3L NP. On assessment, he had a
moist productive cough with right-sided inspiratory coarse crackles. He had a distended
abdomen with an abdominal pain that worsened on palpation. His current medication include
metformin 500mg, captopril 12.5mg, allopurinol 100mg, and paracetamol 1g. Ted might be
having colon cancer since the colonoscopy and biopsy revealed a malign mass. Obesity, as seen
by the client, has been associated with increased risk for colorectal cancer. BMI plays a major
role; increased body size may affect colorectal carcinogenesis. Cancer begins when the body
cells start to go out of control. Polyps start to grow on the inner lining of the rectum or colon.
The polyp usually starts in the innermost layer and grows outwards towards all other layers. The
cancer cells can also grow in the lymph or blood vessels.
Bowel resection surgery was done to remove part of the bowel with the malignant tumor.
During bowel resection, the surgeon removes the diseased part, and the two remaining ends of
the colon are joined using stitches or staples, also called anastomosis. For Ted, anastomosis was
not done; both ends of the colon were attached to an opening on the abdomen. This procedure is
known as colostomy. Four days postoperative Ted had a fever of 38.1, rapid heart rate of 98, and
an increased respiratory rate of 26 breaths per minute and blood pressure of 135/85, which might
be an indication of postoperative sepsis. The specific commodity that increased the risk of Ted
getting postoperative sepsis is diabetes. Individuals with diabetes have a reduced response to
bacteria, causing infections. High blood glucose levels create a suitable environment for the
bacteria to thrive. When blood sugar levels are high, it increases inflammation of body cells and

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prevents oxygen and nutrients from energizing the cells. Delayed wound healing increases the
risk of sepsis.
Problems
Ineffective breathing pattern related to pulmonary edema as evidenced by right-sided
inspiratory coarse crackles, tachypnea (26 breaths per minute) and a moist productive cough. Ted
has a history of heart failure. Systolic and diastolic dysfunction results in reduced cardiac output,
which activates the renin-angiotensin system and sympathetic nervous system. The net effect
produces an arterial vasoconstriction, which helps regulate arterial pressure and increase blood
volume, thus enhancing the stroke volume. This causes the heart to work harder to pump blood,
causing ventricular hypertrophy (Long, Mordi, & Sagar, 2018). Pulmonary congestion takes
place when the left ventricle is not able to pump blood to the rest of the body. Blood volume and
pressure increases in the left atrium hence reducing blood flow to the lungs. Pulmonary blood
volume rises, forcing fluid out of the capillary into the alveoli impairing gaseous exchange
causing pulmonary crackles, cough, and tachypnea.
Pain related to bowel resection surgery as evidenced by patient verbalization of pain 4-
5/10 that worsens on palapation to 7/10, nausea and vomiting, increased heart rate and blood
pressure. The activity of the SA node increases when the sympathetic is more active during pain.
Hyperactivity of the SA node increases the heart rate. The feeling of nausea and vomiting is a
common side effect of pain. Studies show that patients experienced both pain and nausea after a
surgical procedure. Vomiting is usually mediated by the sympathetic, motor, and
parasympathetic (Thienhaus, 2018). Pain activates the motor system causing reverse peristalsis.
Contents in the middle of the small intestines are brought up to the stomach. Contraction of
abdominal musculature and inspiration against closed glottis results in vomiting.

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Question three
a. Ineffective breathing pattern related to pulmonary edema as evidenced by right-sided
inspiratory coarse crackles, tachypnea (26 breaths per minute), and a moist productive
cough.
Goal
Relieve fluid overload symptoms in 72 hours.
Intervention
 Monitor respiratory status, including breath sounds, rate and pattern of respirations.
Pulmonary congestion leads to fluid accumulating in the parenchyma and air spaces in
the lungs. If not corrected, it results in impaired gaseous exchange causing respiratory failure.
Early detection of a deteriorating respiratory system will further prevent complications.
 Encourage the patient to carry out diaphragmatic breathing.
Diaphragmatic breathing assists in strengthening the diaphragm muscle that facilitates
breathing. This mechanism has a ton of benefits. It helps an individual relax, lowering the stress
hormone cortisol in the body. Cortisol prevents insulin production hence inhibiting glucose
uptake in target cells. If not stopped, it may worsen Ted's condition since he already has diabetes.
Cortisol also narrows blood vessels while epinephrine increases heart rate (Shaw, 2017). Patient
relaxation is vital since cortisol constricts blood vessels raising the blood pressure, and the
individual becomes immunocompromised, making them susceptible to infections. Diaphragmatic
breathing uses less energy, and this tends to slow down the breathing rate.
 Assist the patient in maintaining an appropriate position to alleviate breathing by
placing the patient in a supine position through elevating the head of the bed at least
30 degrees.

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The semi-fowlers position helps patients with cardiac and respiratory problems because it
allows air to go easily in and out. The position carries away pressure in specific nerves and
allows gravity to help with issues such as blood flow and breathing. It allows individuals with
cardiac problems to put less stress on their hearts (Nail, Angus, & Sajkov, 2017). The upright
condition prevents abdominal contents from going upwards and prevents lung expansion. This
position facilitates an improves air exchange and lung expansion.
 Asses cough (moist, croupy, brassy) frequency, onset, duration, color, amount and the
patient's ability to swallow or expectorate secretions and educate on the importance of
coughing and coughing technique.
Coughing is a protective mechanism whose function is to remove excessive debris and
secretions from the pulmonary tract. An infective airway clearance impairs airways clearance
and prevents mucus from being removed (Hegland, Bosler, & Davenport, 2017). Cough
assessment is necessary to check if their respiratory muscle fatigue and severe bronchospasm.
The color of mucus could indicate an infection. Thin and clear mucus indicates cold or allergies,
thick and colored my suggest bacterial infection. If the cough produces a rattling sound that may
indicate pneumonia. Coughing keeps the lung expanded and removes any secretions that might
have accumulated as a result of mechanical ventilation or anesthesia (Chung, Fan, & Ian, 2016).
During coughing, bracing the incision site by applying gentle firm pressure supports the incision
site and recuses stress.
 Reposition the patient every two hours.
Positioning provides patient comfort and stability, making them calmer and more
relaxed. Accumulation of mucus along the respiratory tract may compromise the respiratory
system if aspirated (Sekizawa, Ujiie, Sasaki, & Takishima, 2018). For patients with ineffective

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coughing, positioning after every two hours will promote expectoration, improve cough
effectiveness, and improve mucociliary clearance by pushing the secretions to the upper airway.
b. Pain related to bowel resection surgery as evidenced by patient verbalization of pain
4-5/10 that worsens on palpation to 7/10, nausea and vomiting, increased heart rate
and blood pressure.
Goal
The patient verbalizes decreased or absence of pain after 72 hours.
Intervention
 Assess for quality, quantity, location, onset, precipitating, and relieving factors.
Monitor the signs and symptoms that relate to chronic pain such as reduced appetite,
anxiety, changes in body posture, and sleep pattern disturbance.
Pain can be manifested, tolerated, and perceived individually. Pain assessment helps the
nurse differentiate incisional pain from other types of pain, such as angina (Herr, Titler, &
Schilling, 2017). Nonverbal cues such as sleep disturbance will help indicate the degree of pain
being experienced. Physiologic changes that manifested in acute pain vary with the ones in
chronic pain. The guarding behavior seen in acute pain may become relentless with patients with
chronic pain; therefore, distinguishing variables that affect patient pain is significant in
developing a care plan.
 Monitor vital signs
Pain usually causes an increase in heart rate due to the activation of the sympathetic
nervous system controlling the SA node (Felligmn, Baron, & Edwards, 2018). Blood pressure
may slightly increase with incisional discomfort.

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 assess the patient's understanding towards pharmacologic and nonpharmacological
ways of pain management and discuss the advantages of non-pharmacologic
measurements such as cold application, distraction, and progressive relaxation
technique.
Patients may believe in the effectiveness of pharmacologic measurement as a way of
reducing pain and question the capability of non-pharmacologic intervention. Distraction is
worked by increasing the pain threshold. Cold application reduces spasticity, inflammation, and
pain by limiting the production of pain-inducing chemicals and controlling the transmission of
pain impulses.
 Provide enough rest periods to facilitate relief, relaxation, and sleep
The patients' experience of pain may lead to exhaustion. Pain may cause chronic fatigue,
which may exacerbate pain. A quiet and peaceful environment may promote rest.
 Provide comfort measure and provide comfort measures
Provide a position of comfort by using adjuncts such as blankets and pillows, which help
maintain splinting incision and maintaining body alignment to promote comfort (Abu-Saad,
2019). Provision of comfort measures such as backrubs and assistance of self-care activities help
in relaxation techniques and redirect attention.
Question four
a) Analgesics
Analgesics provide relief for both chronic and acute cases. This class of drugs selectively
relieves Ted's pain without obstructing the transmission of nerve impulses sensory perception or
affecting consciousness. They inhibit the production of prostaglandins that induce pain. An

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example of an analgesic is paracetamol, which is given 1d QID. It increases the pain threshold by
blocking COX-1 and COX-2, which activate prostaglandin synthesis (Lewis & Stine, 2017).Side
effects of paracetamol include hepatotoxicity in large doses, nausea, hypertension, and renal
failure. The nurse should check the health condition and alcohol consumption of the patient
before administering paracetamol.
ACE inhibitors
Ted has a history of heart failure and has high blood pressure. This class of drugs is used
to treat high blood pressure by reducing the production of angiotensin, a hormone that constricts
blood vessels. An example of an ACE inhibitor is captopril. It antagonizes the effect of RAAS, a
homeostatic mechanism that controls water and electrolyte balance (Vane, 2019). It inhibits the
conversion of angiotensin 1 to angiotensin 2. Angiotensin-converting enzyme prevents
deactivation of bradykinin, a vasodilator hence reducing blood pressure. Side effects of captopril
include hypotension, abdominal pain, insomnia, constipation, impaired renal function, and
tachycardia. The nurse should monitor for signs of angioedema, check fluid overload that can be
manifested as crackles, dyspnea, and peripheral edema.

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References
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Chung, K., Fan, P., & Ian, D. (2016). Prevalence, pathogenesis, and causes of chronic cough.
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Liao, C., & Qin, Y. (2015). Factors Associated with Stoma Quality of Life Among Stoma
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